11/03/07

Thoughts \ Developed Thoughts \ Rants \ Raves \ Writing

03/11/2007 00:16 -0500 GMT

Insomnia is Ugly

I'm still on Pediatric Surgery. Yesterday was my twelfth day in a row of work. They are long days of at least twelve hours, normally.

Last night I was in bed by 19:45, and asleep before 21:00. However, at precisely 23:36, I looked at the clock, woke up, and couldn't get back to sleep. I turned on the television set, which is a very anti-Feng shui thing to have in one's bedroom. After an hour, I gave up on sleep, and got up. After some time on the computer, I considered going in to the hospital. Why not? I thought, since I was awake. But I waited until the usual time, leaving the house about 4:30.

There is one case on our service that has haunted me. She is 18 months old, and has been horribly abused. She was beaten so badly that her duodenum was severed, and her spleen and kidney were lacerated.  On the operating table, the team noted evidence of rape. On the operating table, she required chest compressions and epinephrine to keep her alive.

Severing the duodenum is no small feat. My resident likened the injury to being hit with the end of a baseball bat with full adult force. The duodenum is situated in the retroperitoneum, in the back of the abdomen, secured by and behind the protective fascia that envelops the majority of the gut. Add to that the kidney and splenic lacerations, which  are associated with blunt force trauma. She must have taken a hell of a beating to get those injuries.

Surgery was extensive. Her duodenum was oversewn, meaning that it was tied off and separated from the remainder of her intestines. It is questionable whether her jejunum, which is the next part of her intestines, will survive. Her large intestine was also oversewn, with an exit made through the skin - a colostomy. The incisions were left open, with further surgery planned. By the end of surgery, she had an esophagogastrointestinal tube that ends at her duodenum, another jejunoileocecal tube that is closed at both ends, and a colon that is exposed to the outside world at the wrong end, as well as at the anus. Because of all the injuries and resulting closed intestinal tubes, she can't take in food, so she is taking parenteral nutrition - food by IV.

A medical problem she has faced now is thrombocytopenia - her platelets are dropping to dangerously low levels - about thirty thousand today. She runs the risk of bleeding. After not sleeping the night before, my task was to discover the reason for her low platelets. Medicines can cause this, and this was the most likely culprit, Heparin being the prime suspect.

Speaking of suspects, when I went to her bedside, the little girl's mother was there. She was from Selma, Alabama, one of the birthplaces of the Civil Rights Movement in America. Her boyfriend, who is a convicted sex offender, has disappeared since my patient first presented to the Children's Hospital of Alabama. The mom is also a suspect in the case. And there she stands, stroking the foot of her baby, surrounded by suspicious glances.

I stood with my back to the bedside as I reviewed the patient's chart. I noted every medicine the baby had taken since arriving here. I noted the ER chart from Selma. I read the imaging reports from both Selma and Birmingham. I talked with the nurses in hushed tones. Underneath my investigations, I was seething at the circumstances of it all.

The girl is conscious now, her eyes move to different faces, but she speaks none of the few words she knows.

I had to swallow my resentment and talk to the mother. I had to cast aside my judgment of her. She probably knows what happened to this girl, I thought. She might know where the man is who attacked this girl, and killed her spirit, if not her physical being. She may have done it herself. Her story is that the girl ran into a table a few days ago. Her story is that something may have happened at Day Care.

Bull to the shit.

I left those thoughts behind, and asked Mom about previous medications in the last week. Amoxicillin for a pneumonia. No aspirin. So on and so on.

I can't help but think that this girl is ruined by her abusers. She is ruined. She may or may not ever be able to enjoy a meal again. She may think that the horrors that I view of her circumstances are normal. She's never known anything different. She's never been given a chance, and she's been permanently robbed of a decent future. Under the best circumstances, with all the resources of the world, she will be affected by her abusers forever.

Her case presents such an ugly scenario that I don't want to face it. I would rather it just didn't exist in my world. And I can easily ignore this little girl's case. I can focus on the surgery. I can choose to not investigate her thrombocytopenia. I can leave it alone, and focus on the other dishes that this rotation has to offer.

Naturally for me, I think of AIDS, and I think about the suboptimal response that is the global response to AIDS - the worst epidemic of my generation. Like this case of abuse, it is easier to turn away from it than to face the horrors of the reality that is going on daily in the lives of those affected by HIV. What I would like to do is make a connection for myself, where I can understand my desire to turn away from this abuse case, and translate that into the world's desire to turn away from AIDS. Then the punch line is to translate that into generating a passionate response in those who do choose to turn away.

Turn back.

At least acknowledge this crisis. Pay more attention when you encounter this problem. As much as I feel that it is my calling to care for those who have AIDS, I feel that I have a responsibility to turn the light back on the epidemic when the global lights are drawn away. If the spotlight shifts off the mark, push it back. I don't know how to do that effectively yet.